How Connected Are You to Your Doctor?

Patients with the strongest relationships to specific primary care physicians are more likely to receive recommended tests and preventive care, a new study found.

PAULINE W. CHEN, M.D.

For several years, I cared for a patient whom I’ll call Marcus. Compact and wiry, with a shock of white hair and blue eyes, Marcus was in his 70s when he developed liver cancer. At our first meeting, I was hesitant to put him through an operation based on his age alone. But then he mentioned the work he had done during his youth: he had been a lion tamer.

“Weren’t you ever scared?” I blurted out.

“No,” he replied with a sly smile. “And if I was, I didn’t let the lions know.”

Marcus eventually had the operation. And while he did well, he struggled with the prolonged recovery, impatient that it would be months before he felt as strong as he had before the operation. He never complained of pain; in fact the only things he ever complained about were my restrictions on his activity. Nonetheless, Marcus gamely followed my orders and returned to our clinic for several postoperative visits, fielding my barrage of questions with the courage of a man who could list “face time with lions” on his résumé.

One afternoon, about two years after the operation, Marcus called me. My stomach dropped when I heard his voice; his confident baritone had turned into a diminutive whimper. “I don’t feel well,” he whispered. “My belly hurts.”

I had never heard Marcus talk like this and immediately asked him to come in. Within a few hours, he was back in the operating room, where I freed up a small loop of intestine that had gotten stuck in a hernia. While Marcus would have eventually had his urgent operation no matter what surgeon he went to see, I cannot help but believe that the strength of our connection expedited his care.

I knew Marcus so well that it was apparent to me, in even a single statement over the phone, that he was gravely ill.

I thought about Marcus and the strong bond we had formed when I read a recent study in The Annals of Internal Medicine that looked at “connectedness” as a measure of the patient-doctor relationship. Researchers at the Massachusetts General Hospital in Boston created an algorithm that took into account factors like how long it had been since the patient last visited the doctor and whether or not primary care physicians could distinguish the patient as “my patient,” as a patient shared with practice partners, or as one to whom they had merely been assigned.

Using the algorithm, the investigators studied over 155,000 patients. The good news is that about 60 percent of patients studied had the kind of relationship with their specific doctors that could be considered “connected.” But a sizable minority did not. About one in three patients were merely “connected” to an entire practice of physicians but not a single doctor; and just over 5 percent of patients were not “connected” at all.

The investigators then examined the frequency with which these patients underwent certain preventive health measures, such as mammography, colon cancer screening and cholesterol checks. Not surprisingly, those patients with the strongest relationships to specific primary care physicians were also more likely to receive recommended tests and preventive care. In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex, race or ethnicity.

The study results make sense to me, both intuitively and from experience. I am not a primary care physician like those studied, but I have patients like Marcus whom I have known for years. I know about their work and their families, and they know about mine. And it makes a difference when I know their clinical “baseline.”

I called Dr. Steven J. Atlas, the lead author and co-director of primary care quality improvement at Massachusetts General Hospital in Boston to ask him more about patient-doctor connectedness and how it could be improved.

“From the health system perspective,” Dr. Atlas said, “it’s kind of old fashioned that a patient who comes to see you is yours. But when you take a step back, it gets more complicated. How much of this connection is influenced by physician practice factors and how much is influenced by patients?”

“Some primary care physicians practice in much more of a solo practice model, some physicians practice in a more collaborative model. And many primary care doctors are now part-time,” Dr. Atlas observed. “But a lot of the relationship is influenced by patients, as well. For example, patients who are from a different culture, who don’t speak English, or who have no insurance or income may see doctors only when they need to.”

We discussed different practice models, including doctors in walk-in clinics, so called “Docs-in-the Box.” “That business model says we are fulfilling a need,” Dr. Atlas said, “but is it really what patients want, or is it the only thing they can get? You could argue that the way we provide care now is to meet our needs as physicians. We are telling patients what we want to do. What we have to do is flip that around.”

Dr. Atlas continued, “There are a lot of other care models that we need to think about if we are to deliver care in a way that is congruent with patient beliefs and lifestyle. It’s not just connecting a patient with a specific doctor. I suspect many patients would like that, but for other patients, even with enough primary care doctors, that model would not be sufficient.”

He paused, then added, “Maybe we need more visits by phone, e-mail and iChat, or by patients taking a photo of their rash then e-mailing it.”

As we discussed different models of health care delivery, it became clearer to me how important it was to be able to compare, and not just assume, each model’s effects on the patient-doctor relationship. “What we have published is common sense,” Dr. Atlas said. “But if you are going to organize care efficiently for patients, you need to be able to measure the quality and patterns of care. We can now measure ‘connectedness’ in real time and use this information to direct initiatives that are having an impact.”

“The doctor-patient relationship is a good thing,” he continued, “but for the last 25 years that relationship has been deteriorating. By focusing on new treatments, new technology and instant access, we have undermined the patient’s ability to have a longstanding relationship with a doctor, to have a doctor who knows him or her as a human being. If all your primary care doctor does is order tests and make referrals to specialists, he or she will miss the fact that you are stressed out because you lost your job or your health insurance.”

Dr. Atlas reflected for a moment before adding, “And we will have missed the forest for the trees.”

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